The cost of infertility evaluation and therapy: findings of a self-insured university healthcare plan

The potential use of intrauterine insemination as a basic option for infertility: a review for technology-limited medical settings

Objective. There is an asymmetric allocation of technology and other resources for infertility services. Intrauterine insemination (IUI) is a process of placing washed spermatozoa transcervically into the uterine cavity for treatment of infertility. This is a review of literature for the potential use of IUI as a basic infertility treatment in technology-limited settings. Study design. Review of articles on treatment of infertility using IUI. Results. Aspects regarding the use of IUI are reviewed, including ovarian stimulation, semen parameters associated with good outcomes, methods of sperm preparation, timing of IUI, and number of inseminations. Implications of the finding in light of the needs of low-technology medical settings are summarized. Conclusion. The reviewed evidence suggests that IUI is less expensive, less invasive, and comparably effective for selected patients as a first-line treatment for couples with unexplained or male factor infertility. Those couples may be offered three to six IUI cycles in technology-limited settings.

Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.

'Cheaper than a newcomer': on the social production of IVF policy in Israel

This paper explores the shaping of health policy in terms of power relations and group interests, as enacted in Israel's IVF policy. A comparison with the principles of IVF provision in other countries (UK, Canada, USA) shows Israel's policy to be substantially more 'liberal'. In order to explain this exception, the policy is initially located within the context of the state's pro-natalist reproductive policy, women's impaired equality and a complex system of healthcare provision. A Parliament Committee discussion on the subject is then analysed in greater detail, revealing three narratives that are used to account for the state's IVF policy: a nationalised narrative of reproductive medicine as a source of international acclaim, a personalised narrative of compassion for anguished women, and a medicalised narrative of experts as being best capable of regulating IVF. All three narratives have merged within the local IVF discourse, enabling the creation and maintenance of consensus among the participating politicians, physicians, consumers and women activists. Of significance is the muted argument regarding the state's interest in enlarging its Jewish population, which dominated other discussions on this topic. I argue that it is the demographic interest which crucially underlies the state's willingness to sustain its costly IVF policy, and that it is this interest which has enabled the various participants--who all shared an interest in unlimited IVF provision--to present a unanimous agreement. State representatives then used this consensus as a firm civil ground for the development and maintenance of Israel's exceptional IVF policy. The paper concludes with several implications regarding women's health and wellbeing.

Assessing the quality of infertility resources on the World Wide Web: tools to guide clients through the maze of fact and fiction

The Internet has become a major source of health information for women, but information placed on the World Wide Web does not routinely undergo a peer review process before dissemination. In this study, we present an analysis of 197 infertility-related Web sites for quality and accountability, using JAMA's minimal core standards for responsible print. Only 2% of the web sites analyzed met all four recommended standards, and 50.8% failed to report any of the four. Commercial web sites were more likely to fail to meet minimum standards (71.2%) than those with educational (46.8%) or supportive (29.8%) elements. Web sites with educational and informational components were most common (70.6%), followed by commercial sites (52.8%) and sites that offered a forum for infertility support and activism (28.9%). Internet resources available to infertile patients are at best variable. The current state of infertility-related materials on the World Wide Web offers unprecedented opportunities to improve services to a growing number of e-health users. Because of variations in quality of site content, women's health clinicians must assume responsibility for a new role as information monitor. This study provides assessment tools clinicians can apply and share with clients.

The economic consequences of multiple gestation pregnancy in assisted conception cycles

This study estimates the projected costs of multiple births resulting from assisted conception cycles (in vitro fertilization with or without intracytoplasmic sperm injection and ovarian stimulation with gonadotrophin). The estimates are modelled from the volume of services, treatment success and multiple gestation rates in recent registry data. The coverage is restricted to hospital costs associated with delivery and the trends are projected to 2000 in the United States. Sensitivity analyses tested different assumptions about per annum trends in effectiveness, multiple pregnancy rates and health costs. The national cost of in vitro fertilization cycles is US$470.2 million (£313.5 million) and the cost of the multiple pregnancies from in vitro fertilization is US$639.9 million (£426.7 million). The national cost of ovarian stimulation cycles is US$166.6 million (£111.1 million) and the cost of the multiple pregnancies from ovarian stimulation is US$257.3 million (£171.6 million). Although costs are a limited indicator of the burden of illness, the projected national cost of multiple pregnancy associated with assisted conception in 2000 is greater than the base cost of the treatment. Prevention of multiple pregnancy in assisted conception cycles should be a priority.

Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics

OBJECTIVE

To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change.

DESIGN

Narrative literature review, policy analysis.

SETTING

University Department of Obstetrics and Gynecology.

PATIENT(S)

Sub-fertile women and men.

INTERVENTION(S)

Fertility treatments, in particular IVF.

RESULT(S)

The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued.

CONCLUSION(S)

Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.

A one-year experience with a capitated health care plan for infertility

OBJECTIVE

To report on a one-year experience participating in a capitated healthcare plan for infertility.

DESIGN

Prospective study.

SETTING

University population.

PATIENT(S)

Reproductive-age women 15 to 50 years.

INTERVENTION(S)

The first-generation Lewin infertility algorithm and CATHI software were used to negotiate infertility services under a capitated arrangement for $0.50 per member per month. The following reports our experience for the fiscal year 1997.

MAIN OUTCOME MEASURE(S)

Infertility services rendered, pregnancy rate, cost of services, collection rates.

RESULT(S)

Five thousand forty-six women representing 39,689 member months generated 39 new and 198 return visits. Thirty-two percent of the patients required three visits or less; six patients generated 22% of the visits. Fifty-one percent listed infertility as one of their chief complaints; 31% had mixed diagnoses. Eight (7.6%) patients required surgery, 11 (10.5%) patients underwent either IVF or GIFT cycles. Total charges submitted were $176,636; the amount assigned to specialty care was $135,277, and to IVF/GIFT, $33,433. Total capitated payments, including copayments, was $126,256 under the reproductive medicine agreement and $32,891 under the infertility rider. This resulted in a 71% gross collections rate.

CONCLUSION(S)

This study indicates that entering into a capitated health care plan to provide an infertility benefit can produce a successful result.

Cost-effective treatment for the couple with infertility

Although the evaluation of cost-effective approaches to infertility treatment remains in its infancy, several important principles have emerged from the initial studies in this field. Currently, in treating couples with infertility without tubal disease or severe male-factor infertility, the most cost-effective approach is to start with IUI or superovulation-IUI treatments before resorting to IVF procedures. The woman's age and number of sperm present for insemination are significant factors influencing cost-effectiveness. The influence of certain diagnoses on the cost-effectiveness of infertility treatments requires further study. Even when accounting for the costs associated with multiple gestations and premature deliveries, the cost of IVF decreases within the range of other cost-effective medical procedures and decreases to less than the willingness to pay for these procedures. Indeed, for patients with severe tubal disease, IVF has been found to be more cost-effective than surgical repair. The cost-effectiveness of IVF will likely improve as success rates show continued improvements over the course of time. In addition, usefulness of embryo selection and practices to reduce the likelihood of high-order multiple pregnancies, without reductions in pregnancy rates, will significantly impact cost-effectiveness. The exclusion of infertility treatments from insurance plans is unfortunate and accentuates the importance of physicians understanding the economics of infertility treatment with costs that are often passed directly to the patient. The erroneous economic policies and judgments that have led to inequities in access to infertility health care should not be tolerated.